Thursday, August 10, 2017

While many people contributed to the defeat of the current
efforts by Congress to repeal the Affordable Care Act (ACA), physicians had a
big role in organizing opposition to repeal, individually and collectively
through their professional societies—including through the American College of
Physicians.It was a redemptive moment
for American medicine, making up in part for its sad, sorry history of opposing
health insurance for all.

It is sobering to review the medical profession’s century-long
history of being unyielding opponents of universal coverage. To put a finer point on it, it was organized medicine—mainly the American
Medical Association (AMA) and state medical societies—that opposed universal
coverage or even partial steps toward it, since specialty societies for the
most part were not involved in advocacy until the 1970s or later.Even when the specialties began to take on
advocacy, they mostly addressed narrow issues that directly affected their own
disciplines. This left the AMA and the state medical societies to speak for
doctors on issues like access and coverage.

In 1920, the AMA’s House of Delegates officially came out
against what was called “compulsory health insurance” which “was viewed as a
threat to professionalism itself, requiring acceptance of mandatory fee
schedules, work reviews, organizations outside the doctor-patient relationship
over which doctors have no control; and limits on patient choice of physician,”
wrote Rosemary Stevens in her insightful book American
Medicine and the Public Interest, originally published in 1971 and
updated in 1998.

The AMA’s opposition to universal coverage was so powerful
that President Franklin Roosevelt did not include national health insurance
with the recommendations that formed the basis of the Social Security Act of
1935 because “he feared, probably correctly, that because health insurance had
such strong opposition from physicians [namely, the AMA] and others, if it were
included in his program for economic security, he might lose the entire program,”
wrote Robert M. Ball, in “Reflections on How Medicare Came About” in Medicare:
Preparing for the Challenges of the 21st Century. Ball ran the Social
Security program from 1962 to 1973, and he helped design Medicare for the
Johnson administration.

When President Harry S. Truman advocated for national health
insurance in 1948, “the AMA’s opposition approached hysteria,” Ball continued, noting
that the AMA raised a “$3.5 million war chest—very big money for the time—with
which it conducted a campaign of vituperation against the advocates of national
health insurance.”

In the early 1960s, the AMA vehemently opposed the enactment
of Medicare, even though Medicare as originally proposed by the Kennedy and
Johnson administrations would have applied only to hospital services (coverage
for physician services through the voluntary Medicare Part B program was added
late in the process at the request of Congressman Wilbur Mills, the
then-chairman of the Ways and Means Committee).“If physician services were left out entirely, we reasoned, the AMA’s
opposition would have less standing,” Ball wrote.“By that time it was clear that the elderly
had the most political appeal and potentially the most muscle.We wanted to get
something going, and this seemed a plausible first step.”The AMA also opposed Medicaid, the sister
program to provide coverage to some categories of poor women and children.

Although the AMA lost its fight against Medicare and
Medicaid, both of which were signed into law by President Johnson on July 30,
1965, it continued to resist most efforts to expand the government’s role in
health care through the 1970s and 80s. By the 1990s though, the AMA had
tempered its views, and while it never got behind President Clinton’s failed
Health Security Act, it also was no longer an unyielding opponent.The AMA even put its support behind programs
to incrementally expand coverage, including the Children’s Health Insurance
Program enacted in 1998.

This brings us to Obamacare. The AMA engaged constructively
with President Obama and the congressional leadership on the Affordable Care
Act, offering its qualified support for the bill leading up to its enactment in
March, 2010. And, the AMA opposes the current efforts by President Trump and
the GOP-controlled Congress to repeal and replace Obamacare with something that
would cover fewer people and offer less protection for people with preexisting
conditions.A sign of how much things
have changed for the AMA is when its House of Delegates in June of this year resoundingly
voted to oppose any legislative proposals to cap Medicaid—in
other words, to keep it an open-ended entitlement program.This is not your grandfather’s AMA, for sure.

The AMA’s evolution to supporting some variations of
universal coverage is welcome and necessary. Its speaking out against the
current efforts to repeal the ACA should be applauded.Yet, it also must be acknowledged that many
other physician organizations, representing even more doctors than the AMA can
now claim as members, have made it their mission and their passion to advocate
for universal coverage and against ACP repeal.

I am particularly proud of the ACP’s leadership.The ACP first came out for universal coverage
in the 1990s, gave qualified support to President Bill Clinton’s Health
Security Act, and became a leading advocate during President Obama’s
administration for what became the Affordable Care Act.But the current efforts by President Trump
and the GOP-controlled Congress to repeal the ACA really tested ACP’s
mettle.And the College passed the test,
with flying colors.

ACP helped organize and lead a coalition of six front-line
physician membership organizations—the American College of Physicians, American
Academy of Family Physicians, American Academy of Pediatrics, American Congress
of Obstetricians and Gynecologists, American Osteopathic Association, and
American Psychiatric Association—to advocate for preserving coverage and
opposing efforts to repeal and replace the ACA with alternatives that would
leave millions more without health insurance. Collectively, the coalition
represents over 560,000 physician and medical student members, the vast
majority of front-line physicians in the United States. The six allied groups
above have conducted 5 separate fly-ins (2-2-17, 3-7-17, 5-11-17, 6-28-17,
7-12-17) involving the leadership of those six front-line physician
organizations, the most recent one was July 12.Meetings were held with targeted representatives and senators. 100
letters were hand delivered on June 28 to all Senate offices, signed by the
group of six, containing state-specific data on the harmful impact of the
Senate’s Better Care Reconciliation Act in each state.

ACP, on its own, sent at least 36 action alerts to our
grassroots network across the country, which includes targeted alerts to key
House members and senators; conducted a “write to Congress” letter-writing
campaign for all of our 50 chapter governors during our March Board of
Governors meeting; launched 7 separate full-scale action campaigns for our 50
chapters that also involved targeted campaigns for 8-10 states with Republican
senators who had expressed concerns about the repeal bills; sent 15 ACP
National letters to Congress; sent 14 coalition letters to Congress; had 3 TV
appearances on MSNBC, on “the Last Word” and with Kate Snow; sent 28 ACP and/or
joint releases/statements on repeal efforts;conducted local TV interviews that reached 16.2 million people with 549
airings of the content; and organized a social media campaign (including
through my @BobDohertyACP
twitter account) to organize opposition to repeal.And this is only a partial list of our
efforts! You can learn more about ACP’s activities on our website.

Our efforts, and those of so many others, paid off in the
wee hours of July 28 when Senator John McCain joined Senators Susan Collins and
Lisa Murkowski to cast their votes against Majority Leader McConnell’s last
ditch effort to get repeal through the Senate.

That ACP, our sister coalition partners, today’s AMA,
Doctors for America, the National Physicians Alliance, and many other
organizations representing physicians, have done so much now to save coverage
and access for millions cannot completely make up for a century of doctors
failing their patients by opposing Medicare, Medicaid, and universal coverage.
It doesn’t change the fact that there is a strong minority of physicians today
who continue to believe, like the AMA in 1920, that universal coverage is “a
threat to professionalism itself, requiring acceptance of mandatory fee
schedules, work reviews, organizations outside the doctor-patient relationship
over which doctors have no control; and limits on patient choice of physician”—one
of whom, Dr. Tom Price, is now Secretary of the Department of Health and Human
Services;every current Republican physician
who serves in Congress today holds similar views. It doesn’t change the fact
that many other physician membership organizations were missing-in-action in
opposing the current efforts to repeal coverage for millions, including most of
the surgical specialty societies and many of the state medical societies. So
yes, too many physicians today still hold views that led their predecessors to
oppose every reasonable effort by the government to extend coverage to
everyone.

But a much larger majority of physicians today have taken a
stand for coverage, for their patients, and against efforts to take it away
from them. Nothing can change history, when that was not the case, but it is
redemptive to see the medical profession today do the right thing by their patients.

Today’s question: What do you think of the medical
profession’s century-long history of opposing universal coverage, and the
efforts by many physicians today to stand up for coverage and against ACA
repeal?